Using CDS Hooks to increase SMART on FHIR app utilization: a cluster-randomized trial.

OBJECTIVE: HL7 SMART on FHIR apps have the potential to improve healthcare delivery and EHR usability, but providers must be aware of the apps and use them for these potential benefits to be realized. The HL7 CDS Hooks standard was developed in part for this purpose. The objective of this study was to determine if contextually relevant CDS Hooks prompts can increase utilization of a SMART on FHIR medical reference app (MDCalc for EHR). MATERIALS AND METHODS: We conducted a 7-month, provider-randomized trial with 70 providers in a single emergency department. The intervention was a collection of CDS Hooks prompts suggesting the use of 6 medical calculators in a SMART on FHIR medical reference app. The primary outcome was the percentage of provider-patient interactions in which the app was used to view a recommended calculator. Secondary outcomes were app usage stratified by individual calculators. RESULTS: Intervention group providers viewed a study calculator in the app in 6.0% of interactions compared to 2.6% in the control group (odds ratio = 2.45, 95% CI, 1.2-5.2, P value .02), an increase of 130%. App use was significantly greater for 2 of 6 calculators. DISCUSSION AND CONCLUSION: Contextually relevant CDS Hooks prompts led to a significant increase in SMART on FHIR app utilization. This demonstrates the potential of using CDS Hooks to guide appropriate use of SMART on FHIR apps and was a primary motivation for the development of the standard. Future research may evaluate potential impacts on clinical care decisions and outcomes.

Accuracy of the Veterans Health Administration COVID-19 (VACO) Index for predicting short-term mortality among 1307 US academic medical centre inpatients and 427 224 US Medicare patients.

BACKGROUND: The Veterans Health Administration COVID-19 (VACO) Index predicts 30-day all-cause mortality in patients with COVID-19 using age, sex and pre-existing comorbidity diagnoses. The VACO Index was initially developed and validated in a nationwide cohort of US veterans-we now assess its accuracy in an academic medical centre and a nationwide US Medicare cohort. METHODS: With measures and weights previously derived and validated in US national Veterans Health Administration (VA) inpatients and outpatients (n=13 323), we evaluated the accuracy of the VACO Index for estimating 30-day all-cause mortality using area under the receiver operating characteristic curve (AUC) and calibration plots of predicted versus observed mortality in inpatients at a single US academic medical centre (n=1307) and in Medicare inpatients and outpatients aged 65+ (n=427 224). RESULTS: 30-day mortality varied by data source: VA 8.5%, academic medical centre 17.5%, Medicare 16.0%. The VACO Index demonstrated similar discrimination in VA (AUC=0.82) and academic medical centre inpatient population (AUC=0.80), and when restricted to patients aged 65+ in VA (AUC=0.69) and Medicare inpatient and outpatient data (AUC=0.67). The Index modestly overestimated risk in VA and Medicare data and underestimated risk in Yale New Haven Hospital data. CONCLUSIONS: The VACO Index estimates risk of short-term mortality across a wide variety of patients with COVID-19 using data available prior to or at the time of diagnosis. The VACO Index could help inform primary and booster vaccination prioritisation, and indicate who among outpatients testing positive for SARS-CoV-2 should receive greater clinical attention or scarce treatments.

Usage Patterns of Web-Based Stroke Calculators in Clinical Decision Support: Retrospective Analysis.

BACKGROUND: Clinical scores are frequently used in the diagnosis and management of stroke. While medical calculators are increasingly important support tools for clinical decisions, the uptake and use of common medical calculators for stroke remain poorly characterized. OBJECTIVE: We aimed to describe use patterns in frequently used stroke-related medical calculators for clinical decisions from a web-based support system. METHODS: We conducted a retrospective study of calculators from MDCalc, a web-based and mobile app-based medical calculator platform based in the United States. We analyzed metadata tags from MDCalc's calculator use data to identify all calculators related to stroke. Using relative page views as a measure of calculator use, we determined the 5 most frequently used stroke-related calculators between January 2016 and December 2018. For all 5 calculators, we determined cumulative and quarterly use, mode of access (eg, app or web browser), and both US and international distributions of use. We compared cumulative use in the 2016-2018 period with use from January 2011 to December 2015. RESULTS: Over the study period, we identified 454 MDCalc calculators, of which 48 (10.6%) were related to stroke. Of these, the 5 most frequently used calculators were the CHA2DS2-VASc score for atrial fibrillation stroke risk calculator (5.5% of total and 32% of stroke-related page views), the Mean Arterial Pressure calculator (2.4% of total and 14.0% of stroke-related page views), the HAS-BLED score for major bleeding risk (1.9% of total and 11.4% of stroke-related page views), the National Institutes of Health Stroke Scale (NIHSS) score calculator (1.7% of total and 10.1% of stroke-related page views), and the CHADS2 score for atrial fibrillation stroke risk calculator (1.4% of total and 8.1% of stroke-related page views). Web browser was the most common mode of access, accounting for 82.7%-91.2% of individual stroke calculator page views. Access originated most frequently from the most populated regions within the United States. Internationally, use originated mostly from English-language countries. The NIHSS score calculator demonstrated the greatest increase in page views (238.1% increase) between the first and last quarters of the study period. CONCLUSIONS: The most frequently used stroke calculators were the CHA2DS2-VASc, Mean Arterial Pressure, HAS-BLED, NIHSS, and CHADS2. These were mainly accessed by web browser, from English-speaking countries, and from highly populated areas. Further studies should investigate barriers to stroke calculator adoption and the effect of calculator use on the application of best practices in cerebrovascular disease.

Establishing a multidisciplinary initiative for interoperable electronic health record innovations at an academic medical center.

OBJECTIVE: To establish an enterprise initiative for improving health and health care through interoperable electronic health record (EHR) innovations. MATERIALS AND METHODS: We developed a unifying mission and vision, established multidisciplinary governance, and formulated a strategic plan. Key elements of our strategy include establishing a world-class team; creating shared infrastructure to support individual innovations; developing and implementing innovations with high anticipated impact and a clear path to adoption; incorporating best practices such as the use of Fast Healthcare Interoperability Resources (FHIR) and related interoperability standards; and maximizing synergies across research and operations and with partner organizations. RESULTS: University of Utah Health launched the ReImagine EHR initiative in 2016. Supportive infrastructure developed by the initiative include various FHIR-related tooling and a systematic evaluation framework. More than 10 EHR-integrated digital innovations have been implemented to support preventive care, shared decision-making, chronic disease management, and acute clinical care. Initial evaluations of these innovations have demonstrated positive impact on user satisfaction, provider efficiency, and compliance with evidence-based guidelines. Return on investment has included improvements in care; over $35 million in external grant funding; commercial opportunities; and increased ability to adapt to a changing healthcare landscape. DISCUSSION: Key lessons learned include the value of investing in digital innovation initiatives leveraging FHIR; the importance of supportive infrastructure for accelerating innovation; and the critical role of user-centered design, implementation science, and evaluation. CONCLUSION: EHR-integrated digital innovation initiatives can be key assets for enhancing the EHR user experience, improving patient care, and reducing provider burnout.

Risk Stratification of COVID-19 Patients Using Ambulatory Oxygen Saturation in the Emergency Department.

INTRODUCTION: It is difficult to determine illness severity for coronavirus disease 2019 (COVID-19) patients, especially among stable-appearing emergency department (ED) patients. We evaluated patient outcomes among ED patients with a documented ambulatory oxygen saturation measurement. METHODS: This was a retrospective chart review of ED patients seen at New York University Langone Health during the peak of the COVID-19 pandemic in New York City. We identified ED patients who had a documented ambulatory oxygen saturation. We studied the outcomes of high oxygen requirement (defined as >4 liters per minute) and mechanical ventilation among admitted patients and bounceback admissions among discharged patients. We also performed logistic regression and compared the performance of different ambulatory oxygen saturation cutoffs in predicting these outcomes. RESULTS: Between March 15-April 14, 2020, 6194 patients presented with fever, cough, or shortness of breath at our EDs. Of these patients, 648 (11%) had a documented ambulatory oxygen saturation, of which 165 (24%) were admitted. Notably, admitted and discharged patients had similar initial vital signs. However, the average ambulatory oxygen saturation among admitted patients was significantly lower at 89% compared to 96% among discharged patients (p<0.01). Among admitted patients with an ambulatory oxygen saturation, 30% had high oxygen requirements and 8% required mechanical ventilation. These rates were predicted by low ambulatory oxygen saturation (p<0.01). Among discharged patients, 50 (10%) had a subsequent ED visit resulting in admission. Although bounceback admissions were predicted by ambulatory oxygen saturation at the first ED visit (p<0.01), our analysis of cutoffs suggested that this association may not be clinically useful. CONCLUSION: Measuring ambulatory oxygen saturation can help ED clinicians identify patients who may require high levels of oxygen or mechanical ventilation during admission. However, it is less useful for identifying which patients may deteriorate clinically in the days after ED discharge and require subsequent hospitalization.

Myopericarditis as a Presenting Feature of Acute Myeloid Leukemia.

BACKGROUND: Myocarditis is a rare sequelae of acute myeloid leukemia (AML) and typically presents after the initial diagnosis of AML has been made. CASE REPORT: We present the case of a 37-year-old female who came to the emergency department with chest pain, ST elevations on electrocardiogram, and a positive point-of-care troponin. She was brought emergently to the cardiac catheterization laboratory. After a negative catheterization, blasts were noted on the complete blood count, ultimately leading to the diagnosis of AML, with myopericarditis as the presenting manifestation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the need for emergency physicians to consider a broad differential for chest pain, especially in those who do not fit into the prototypical patient with acute coronary syndrome.

Calculated decisions: COVID-19 calculators during extreme resource-limited situations.

In the near future, clinicians may face scenarios in which there are not have enough resources (ventilators, ECMO machines, etc) available for the number of critically sick COVID-19 patients. There may not be enough healthcare workers, as those who are positive for COVID-19 or those who have been exposed to the virus and need to be quarantined. During these worst-case scenarios, new crisis standards of care and thresholds for intensive care unit (ICU) admissions will be needed. Clinical decision scores may support the clinician's decision-making, especially if properly adapted for this unique pandemic and for the patient being treated. This review discusses the use of clinical prediction scores for pneumonia severity at 3 main decision points to examine which scores may provide value in this unique situation. Initial data from a cohort of over 44,000 COVID-19 patients in China, including risk factors for mortality, were compared with data from cohorts used to study the clinical scores, in order to estimate the potential appropriateness of each score and determine how to best adjust results at the bedside.

Time trends in use of the CHADS2 and CHA2 DS2 VASc scores, and the geographical and specialty uptake of these scores from a popular online clinical decision tool and medical reference.

BACKGROUND: The impact of the utilisation of such e-health approaches, including mHealth (use of mobile phones and other wireless technology in the delivery of medical care) assessments of health parameters, or the use of decision aids and online risk calculators over time have not been previously described. The objective of this analysis is to assess the time trends in use of the CHADS2 and CHA2 DS2 VASc scores in e-health, and the geographical and specialty uptake of these scores, using data gleaned from a popular online clinical decision tool and medical reference, MDCalc. We hypothesised that the change in use of the scores would reflect the changes in guidelines and trends in clinical practice. RESULTS: The CHA2 DS2 VASc score was the 20th most popular calculator in 2012, rising to the second most popular calculator in 2018; the CHADS2 score showed the converse, dropping from no. 3 to no. 22. Use of the CHA2 DS2 VASc scores particularly increased in the United States, Canada and Australia over time while the United Kingdom experienced a greater traffic share in 2015. The majority users of the CHADS2 and CHA2 DS2 VASc scores were primary care physicians, with cardiologists being in the minority; the proportion of cardiologists was greater outside USA, compared to within USA. CONCLUSION: Over time, use of the CHA2 DS2 VASc score increased, while use of the CHADS2 score decreased. The change in uptake could partly be related to introduction of guidelines recommending the use of the CHA2 DS2 VASc score for stroke risk stratification.

The Prevalence of Cannabinoid Hyperemesis Syndrome Among Regular Marijuana Smokers in an Urban Public Hospital.

Epidemiological data, including prevalence, for cannabinoid hyperemesis syndrome (CHS) remain largely unknown. Without these data, clinicians often describe CHS as 'rare' or 'very rare' without supporting evidence. We seek to estimate the prevalence of CHS in a population of patients presenting to a socio-economically and racially diverse urban Emergency Department of a public hospital. This study consisted of a questionnaire administered to a convenience sample of patients presenting to the ED of the oldest public hospital in the United States. Trained Research Associates (RAs) administered the questionnaire to patients between the ages of 18-49 years who reported smoking marijuana at least 20 days per month. The survey included questions related to CHS symptoms (nausea and vomiting) and Likert scale rankings on eleven symptom relief methods, including 'hot showers'. Patients were classified as experiencing a phenomenon consistent with CHS if they reported smoking marijuana at least 20 days per month and also rated 'hot showers' as five or more on the ten-point symptom relief method Likert scale for nausea and vomiting. Among 2127 patients approached for participation, 155 met inclusion criteria as smoking 20 or more days per month. Among those surveyed, 32.9% (95% CI, 25.5-40.3%) met our criteria for having experienced CHS. If this is extractable to the general population, approximately 2.75 million (2.13-3.38 million) Americans may suffer annually from a phenomenon similar to CHS.

Hurricane Sandy: Impact on Emergency Department and Hospital Utilization by Older Adults in Lower Manhattan, New York (USA).

BACKGROUND: On October 29th, 2012, Hurricane Sandy caused a storm surge interrupting electricity with disruption to Manhattan's (New York, USA) health care infrastructure. Beth Israel Medical Center (BIMC) was the only fully functioning major hospital in lower Manhattan during and after Hurricane Sandy. The impact on emergency department (ED) and hospital use by geriatric patients in lower Manhattan was studied. METHODS: The trends of ED visits and hospitalizations in the immediate post-Sandy phase (IPS) during the actual blackout (October 29 through November 4, 2012), and the extended post-Sandy phase (EPS), when neighboring hospitals were still incapacitated (November 5, 2012 through February 10, 2013), were analyzed with baseline. The analysis was broken down by age groups (18-64, 65-79, and 80+ years old) and included the reasons for ED visits and admissions. RESULTS: During the IPS, there was a significant increase in geriatric visits (from 11% to 16.5% in the 65-79 age group, and from 6.5% to 13% in the 80+ age group) as well as in hospitalizations (from 22.7% to 25.2% in the 65-79 age group, and from 17.6% to 33.8% in the 80+ age group). However, these proportions returned to baseline during the EPS. The proportions of the categories "dialysis," "respiratory device," "social," and "syncope" in geriatric patients in ED visits were significantly higher than younger patients. The increases of the categories "medication," "dialysis," "respiratory device," and "social" represented two-thirds of absolute increase in both ED visits and admissions for the 65-79 age group, and half of the absolute increase in ED visits for the 80+ age group. The categories "social" and "respiratory device" peaked one day after the disaster, "dialysis" peaked two days after, and "medication" peaked three days after in ED visit analysis. CONCLUSIONS: There was a disproportionate increase in ED visits and hospitalizations in the geriatric population compared with the younger population during the IPS. The primary factor of the disproportionate impact on the geriatric population appears to be from indirect effects of the hurricane, mainly due to the subsequent power outages, such as "dialysis," "respiratory device," and "social." Further investigation by chart review may provide more insights to better aid with future disaster preparedness.

Cannabinoid hyperemesis acute renal failure: a common sequela of cannabinoid hyperemesis syndrome.

We report the case of a 25-year-old man with an 8-year history of daily marijuana use diagnosed with acute renal failure secondary to cannabinoid hyperemesis syndrome. The patient presented with "constant" vomiting for over a day. His symptoms were completely relieved with compulsive hot showering and partially relieved by hot baths, by high ambient room temperature, and transiently after smoking marijuana. The patient was found to have a creatinine of 3.21 and admitted for acute renal failure secondary to cannabinoid hyperemesis syndrome. Cannabinoid hyperemesis syndrome (CHS) is a recently described condition affecting long-term marijuana users. We found 5 other case reports of acute renal failure secondary to CHS [1-5], and a total of 55 case reports of CHS. The unique combination of intractable vomiting and constant hot showers seems to put CHS patients at significant risk of severe dehydration and prerenal failure, a common and distinct entity we suggest be termed cannabinoid hyperemesis acute renal failure (CHARF). The characteristics of cannabinoid hyperemesis acute renal failure patients were similar to CHS patients, except a larger portion were over the age of 30 (4 of 6, vs 30%). Evaluating physicians should maintain a high degree of suspicion for this common sequela of CHS.

Traumatic brain injury: A case-based review.

BACKGROUND: Traumatic brain injuries are common and costly to hospital systems. Most of the guidelines on management of traumatic brain injuries are taken from the Brain Trauma Foundation Guidelines. This is a review of the current literature discussing the evolving practice of traumatic brain injury. DATA SOURCES: A literature search using multiple databases was performed for articles published through September 2012 with concentration on meta-analyses, systematic reviews, and randomized controlled trials. RESULTS: The focus of care should be to minimize secondary brain injury by surgically decompressing certain hematomas, maintain systolic blood pressure above 90 mmHg, oxygen saturations above 93%, euthermia, intracranial pressures below 20 mmHg, and cerebral perfusion pressure between 60-80 mmHg. CONCLUSION: Much is still unknown about the management of traumatic brain injury. The current practice guidelines have not yet been sufficiently validated, however equipoise is a major issue when conducting randomized control trials among patients with traumatic brain injury.

Novel use of a urine pregnancy test using whole blood.

We present the case of a 35-year-old woman with hypotension and abdominal tenderness after acute vomiting and syncope. The patient had been breast-feeding since the birth of a child 8 months earlier, was not yet menstruating, and felt that she was having a reaction to sushi. She was unable to provide a urine sample during initial evaluation, and a drop of whole blood was therefore applied to a qualitative urine human chorionic gonadotropin point-of-care test. This test result was positive for pregnancy, ultrasound revealed free fluid in the abdominal cavity, and emergency laparotomy by our gynecologists confirmed ruptured ectopic pregnancy. Often, patients are too unstable or dehydrated to provide a urine sample; and serum human chorionic gonadotropin testing may be difficult to obtain in a timely fashion. This use of the point-of-care urine qualitative test has not been previously described and may be valuable in cases where rapid diagnosis is critical.